Wingrove Veterinary Services

R.R.#1 8737 Wellington Rd 124
Guelph, ON N1H6H7

(519)856-9541

www.wingrovevet.ca

Please arrive to your appointment just prior to your scheduled time. Due to our current scheduling restrictions, if you are not able to arrive on time, we may need to reschedule your appointment. A cancellation fee may apply if you have not cancelled your appointment without 24 hours notice to us or do not show at your scheduled appointment. Please ensure you ‘check in’ with our reception staff by calling 519-856-9541 upon your arrival at the clinic.

 

Wingrove Veterinary Hospital offers our Medical History Form online so you can complete it in the convenience of your own home or office.

To print and fill out the Medical History form please download here. Please ensure this form is filled out completely upon arrival. 

 

 

Medical History for Appointment Form

Please advise us if your pet NEEDS TO BE MUZZLED for examination (required)

Yes
No
Not Sure


Pet's Name (required)
First Name (required)
Last Name (required)
Your Full Name (required)
First Name (required)
Last Name (required)
Phone Number: (required)

Secondary Phone Number:

E-Mail Address :
Please ensure that you are available by phone at ALL times until your pet is released back into your care.
Please enter Diet and Feeding information
Brand of Food (required)

Amount per Feeding (required)

Frequency of Feeding (required)

Do you feed any people food? (required)

If so what kind of food? (required)

Frequency and amount: (required)

Type of Treats: (required)

Frequency and Amount of Treats: (required)

Check the conditions that apply to your pet (Check the conditions that apply to your pet): (required)
Coughing
Sneezing
Vomiting
Diarrhea
Eye Discharge
Dirty/Itchy Ears
Nasal Discharge
Limping
Skin Issue
New or changed lump
Lethargy
No Concerns
Other
If other, please explain

How long has this condition been going on for and with what frequency? (required)

Has your pet experienced this condition in the past? (required)

Check the symptoms that your pet is currently experiencing: (required)
Not eating
Trouble breathing
Trouble defecating
Trouble urinating
Weight gain
Weight loss
Change in behavior
Change in activity level
No concerns
Other
How long has this symptom been going on for and with what frequency? (required)

Has your pet experienced this symptom in the past? (required)

Please list all medications/ vitamins/ supplements/ preventatives that your pet is currently taking: (required)

Has your pet ever had a reaction to vaccinations? (required)
Yes
No
Not Sure
Please indicate what preventatives (name of prevention) or medications you need a refill of:

Which preventative care procedures are you seeking today? (Select all that apply)
THE RABIES VACCINATION IS MANDATORY BY LAW
Canine: (required)
Rabies Vaccine
Distemper & Influenza Vaccine
Leptospirosis Vaccine
Bordetella Vaccine
Lyme Vaccine
None of the above
Feline: (required)
Rabies Vaccine
Feline FVRCP Vaccine
Feline Leukemia Vaccine
None of the above
(required)
Intestinal Parasite (Fecal) Lab
Heartworm/Tick Parasitology (Blood) test
Annual Full Organ Function Lab Screening Monitoring BloodworkUrinalysis
None of the above
Please list any other issues/ concerns that you would like to discuss at your appointment:

Authorizations:
(required)
A topical treatment will be applied at my expense to any pet with evidence of fleas, flea dirt or ticks. I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital.
(required)
In the unfortunate event of an emergency, illness or injury, and I am unreachable at the phone numbers I provided, I authorize Wingrove Veterinary Services to do whatever is deemed necessary by the attending DVM at my own expense.

Should your pet require hospitalization we will make every effort to reach you; please ensure we have all of your up to date contact information should we need to speak with you urgently. In the event that your pet is hospitalized and stops breathing (respiratory arrest) or their heart stops (cardiac arrest) we must know your wishes concerning treatment. Animals that have been successfully resuscitated with CPR (Cardiopulmonary Resuscitation) are extremely critical and unstable. Brain damage is common as is the likelihood of another respiratory or cardiac arrest, blindness or other impaired mental function or physical impairment. Management of a pet after successful initial resuscitation requires vigilant monitoring for at least 24-48 hours which is costly and the outcome is uncertain. If you wish to be provided with a copy of our "Owner Information and Consent for CPR or DNR" form, please let us know.
Signature - I HAVE READ AND UNDERSTOOD THE INFORMATION ABOVE AND DO NOT HAVE ANY UNANSWERED QUESTIONS (Please type your first and last name): (required)


I wish the staff of Wingrove Veterinary Services to perform CPR on my pet if my pet suffers respiratory or cardiac arrest. I understand that my pet may not respond to CPR or may respond initially and then suffer another arrest later. I understand that my pet may die despite CPR. I understand that if my pet survives because of CPR, he/she may have brain damage or other impairments and will require vigilant monitoring and transfer.
I understand
Signature - I HAVE READ AND UNDERSTOOD THE INFORMATION ABOVE AND DO NOT HAVE ANY UNANSWERED QUESTIONS (Please type your first and last name): (required)


After reviewing the above information I DO NOT want CPR performed on my pet. I understand that if my pet stops breathing and/or his/her heart stops beating that my pet will die unless CPR is performed. I elect to have DNR (do not resuscitate) orders placed on my pet's records OR I elected that the veterinary staff stop the initial attempts at CPR that may have been started while I was being informed of the condition of my pet and my options.
I understand
Signature - I HAVE READ AND UNDERSTOOD THE INFORMATION ABOVE AND DO NOT HAVE ANY UNANSWERED QUESTIONS (Please type your first and last name): (required)

Date: (required)


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